[Difficult diagnosis: acute appendicitis and appendiceal/cecal carcinoma]. / Die schwierige Diagnose: Akute Appendicitis und das Appendix-/Coecumbodencarcinom.

INTRODUCTION: Primary carcinoma of the appendix vermiformis/caecum is very rare. The diagnosis can often be ascertained only postoperatively by histopathological means. Preoperative diagnosis is unusual. METHOD AND RESULTS: We report on five patients with an adenocarcinoma of the appendix/base of caecom, all operated on between July 1998 and October 1999. CONCLUSION: A hemicolectomy "en principe" is not necessary. However, ileocaecal resection should have been performed during the first operation and there should be no positive lymph nodes. Postoperative diagnosis of a carcinoma after simple appendectomy necessitates Reoperation with right hemicolectomy.

Simultaneous analysis of 4- and 5-series lipoxygenase and cytochrome P450 products from different biological sources by reversed-phase high-performance liquid chromatographic technique.

Quantification of lipoxygenase and cytochrome P450 products of both arachidonic acid (AA) and eicosapentaenoic acid (EPA) is of broad interest due to the multiple biological activities of these compounds. We developed a method combining (i) solid-phase extraction, (ii) isocratic reversed-phase high-performance liquid chromatographic separation, and (iii) online photodiode array detection with spectrum analysis for identification and measurement of all main 4- and 5-series eicosanoids (leukotrienes, hydroxyeicosatetraenoic acids/hydroxyeicosapentaenoic acids, epoxyeicosatrienoic acids) within one run. With these procedures, standard mixtures of AA- and EPA-derived lipid mediators were recovered from different biological liquids, like lung perfusate, human bronchoalveolar lavage fluid, and cell supernatant with linear characteristics for each compound. Recoveries of the different lipid mediators exceeded 80% showing excellent reproducibility. Application of the method to isolated, perfused, and ventilated human lungs challenged with the calcium ionophore A23187 and to human neutrophils stimulated in the presence of arachidonic acid and eicosapentaenoic acid with N-formyl-methionyl-leucyl-phenylalanine demonstrated the generation of a large array of lipoxygenase and cytochrome P450 products. Thus, convenient quantification of 4- and 5-series eicosanoids in fluids of biological interest is achieved by a technique comprising solid-phase extraction, isocratic reversed-phase high-performance liquid chromatography, and photodiode array-based online spectrum analysis of eluting compounds.

[Specificity of "combi-effect" after xenogenic discordant heart-lung transplantation]. / Spezifität des "Combi-Effektes" nach xenogen diskordanter Herz-Lungentransplantation.

UNLABELLED: The purpose of this study was to investigate whether the "Combi-Effect" is specific for the transplanted lung tissue or not. METHOD: In a Guinea-pig to rat model we compared the heterotopic heart-lung transplantation (HLTx, n = 5) with a second heart transplantation (DHTx, n = 5) and a combined heart-kidney transplantation (HKTx, n = 5). Apart from the heart transplant survival time we determined the concentrations of histamine, CH-50, IgG, IgM, leucocytes and thrombocytes in the blood. At time of rejection all tissues were examined histologically and immunohistologically (ED-11, IgG, IgM, OX-39, W3-13, ED-1, NKR-P1, OX-19). RESULTS: We could achieve a significant prolongation of the heart transplant survival time by combined HLTx compared to HTx (25' to 12', p < 0.01). DHTx showed no effect (7' 53" to 11' 27"). But after HKTx the cardiac survival was even longer than after HTx and HLTx (62.8' to 12' and 25', p < 0.01). CH-50 showed significant lower concentrations after HLTx (180 U/l) and HKTx (178 U/l) than after HTx (260 U/l). Thrombocytes and leucocytes were lower, concentration of histamine higher than after HTx (p < 0.01). Immunohistologically C3 revealed a lower deposition in the rejected heart transplants after combined HLTx/HKTx than after isolated HTx. CONCLUSION: The "Combi-Effect" is stronger after HKTx than after HLTx. He is not specific for the lung tissue.

[Persistent chylothorax after fracture of the 12th thoracic vertebrae]. / Persistierender Chylothorax nach Fraktur des 12. Brustwirbelkörpers.

We report on a patient who suffered chylothorax 2 months after she had undergone internal fixation of a fracture of her 12th thoracic vertebral body. The pleural effusion was treated by insertion of a chest tube. The chylothorax was managed conservatively. The patient received protein-rich nutrition supplemented with medium-chain triglycerides. As the volume of chylous fluid drained from the pleura had not decreased after 2 weeks, the patient received total parenteral nutrition without any oral intake of calories. Chest X-rays documented the disappearance of the chylothorax. Reexpansion of the lungs was noted, and the costophrenic sinuses could be clearly visualised.

[Use of preoperative infusion cholangiography before laparoscopic cholecystectomy]. / Nutzen der präoperativen Infusionscholangiographie vor laparoskopischer Cholezystektomie.

In the present study, we intend to evaluate whether intravenous cholangiography, performed on a routine basis in the preoperative period, in addition ultrasonography, history or elevations of serum bilirubin and alkaline phosphatase, provides any supplementary information in detecting patients with asymptomatic calculi in the common bile duct before laparoscopic cholecystectomy is carried out. Therefore, 513 patients were included in a retrospective analysis. From our data, we conclude that preoperative intravenous cholangiography cannot be recommended, when costs and risks and a potential benefit for the patient are considered.

[Traumatic bronchus rupture. Pathogenesis, surgical and postoperative management]. / Die traumatische Bronchusruptur. Pathogenese, operatives and postoperatives Management.

Tracheobronchial injuries are rare and associated with other injuries. We report about a traumatic rupture of the left main bronchus into the segmental bronchus of the lower lobe. After resection of the lower lobe a bronchoplastic repair of the main and upper bronchus was performed.

[Preventive lymph node excision in the treatment concept of melanoma of the extremities]. / Die prophylaktische Lymphknotendissektion im Behandlungskonzept des Extremitätenmelanoms.

Since 1979, our treatment protocol for extremity melanoma includes regional lymph node dissection, wide tumor excision and hyperthermic limb perfusion. We report on the results of a follow-up of the 451 patients treated in the first decade. 58.5% of patients presented with a primary tumor, additional 7.4% with a local recurrence or satellite metastases without evidence for further tumor extension. Regional lymph node metastases were not found below a tumor thickness of 1.5 mm; then micrometastases occurred in 5-10%, macrometastases at over 1.9 mm in up to over 15% of tissue specimens. 5-year survival was 90% if nodes were negative, 66% if there were micrometastases and 30% for further lymph node metastases. We conclude that patients may benefit from prophylactic dissection of regional lymph nodes if careful selection according to pathohistological and clinical criteria is performed.

[Value of inguinal lymph node excision in anorectal melanoma]. / Die Wertigkeit der Leistendissektion beim anorektalen Melanom.

The anorectal melanoma is a tumor with an unfavorable prognosis. The surgical removal is the therapy of choice. In the literature the different surgical centers suggest either local excision of the tumor or a more radical surgical procedure, the abdominoperineal resection either with or without inguinal and parailiacal lymph node dissection. Considering all therapeutic results the abdominoperineal resection seems to be the therapy with an advantage regarding the prognosis as the results of our own patients show. A groin lymph node dissection should only be performed if the lymph nodes are enlarged. Comparing studies which demonstrate a favorable prognostic influence of elective groin lymph node dissection are not available. Regarding the poor prognosis of the anorectal melanoma we consider an adjuvant chemo- or immunotherapy to be justified. If this will influence the clinical outcome is still a subject of discussion.

[The importance of mediastinoscopy for accurate lymph node staging]. / Die Bedeutung der Mediastinoskopie für das korrekte Lymphknotenstaging.

The mediastinoscopy (MS) was developed 1959 by Carlens. Since the introduction of computertomography (CT) in the diagnostic of the thorax the MS was no longer used routinely. Because of the introduction of the CT in our clinic we performed only 111 MS between 1981 and 1992, in contrast to 185 MS between 1976 and 1981. No patient died perioperatively. Two patients had to be operated on for bleeding. The sensitivity of the modern CT-scan for a correct preoperative staging of a bronchial carcinoma runs up to 90% and the specifity up to 85%. Therefore a correct preoperative staging can only be reached histologically with the help of a MS. An exception are T1 and T2 tumors because of only 28% mediastinal lymph node metastases. We think that the MS should be performed more often in order to reach a correct, histologically ascertained staging preoperatively.

[Value of systematic lymphadenectomy in stomach carcinoma]. / Die Bedeutung der systematischen Lymphadenektomie beim Magenkarzinom.

In a retrospective study of 157 patients undergoing a curative resection of a gastric carcinoma between 1982 and 1992 the correlation of the lymph node status and histomorphologic parameters of the gastric cancer and the significance of the systematic lymphadenectomy were analysed. The patients were divided into two historical groups (exclusively D1- and systematic D1-/D2-lymphadenectomy). Among the histomorphological parameters only the depth of infiltration (pT) revealed a high correlation with the extent of metastatic lymph node involvement. Tumor form, Laurén-classification and tumor localisation only showed a marginal influence on the nodal status. The overall 5-year survival rate was not significantly changed by the systematic lymphadenectomy, only the subgroup of the UICC-stadium II demonstrated a small benefit. The extended systematic lymph node dissection did not rise the complication rate but lowered the rate of local recurrences. In conclusion, the indication for a systematic lymphadenectomy cannot be deducted from the constellation of different histomorphological parameters, but the feasibility of a systematic lymphadenectomy results from the improvement of staging and survival rate at least for the UICC-II-stadium and the reduction of local recurrences.

[Isolated echinococcosis of the lung]. / Die isolierte Lungenechinokokkose.

This is a report of a 81 year old women with a cyst of echinococcus granulosus, that was almost completely taking over the lower lobe of the left lung. This case study shows on one hand the diagnosis of echinococcosis is a part of the differential diagnosis even for an elderly patient. On the other hand we were able to demonstrate, that elderly patients can benefit from the surgical treatment especially since medication has a lot of side effects and a fairly high rate of failures.

[Use of an endoscopic stapler for transanal widening of anastomotic stenosis]. / Einsatz eines endoskopischen Klammerschneidegerätes zur transanalen Erweiterung einer Anastomosenstenose im Rectum.

Postoperative anastomotic stenosis of the colorectal region are reported in 0.5-13%. We present one patient with a benign anastomotic stenosis after resection of the sigmarectum who was treated using the linear cutter Endopath ELC 35.

[Congenital tracheoesophageal fistula in the adult]. / Congenitale oesophagotracheale Fistel beim Erwachsenen.

Congenital esophago-tracheal and esophago-bronchial fistulae are rare. Symptoms are recurrent pneumonia, cough, dysphagia and pain. The diagnosis is made by bronchoscopy or esophagoscopy. Every time the diagnosis is certain, the fistula has to be exstirpated by means of a thoracotomy and plastic reconstructive flap surgery.

[Surgical treatment of tracheal injuries]. / Chirurgische Behandlung von Trachealverletzungen.

Traumatic and iatrogenic injuries of the trachea are rare. In case of suspected rupture of the trachea a bronchoscopy remains the 'gold standard' of diagnostic procedures. The injuries should be repaired as soon as possible through a right thoracotomy or a collar incision using resorbable sutures. In case of small lesions a conservative treatment may be discussed. Overall the prognosis of tracheal injuries is good.

[Follow-up of heterotopic autotransplantation of splenic tissue after traumatic splenic rupture in childhood]. / Spätergebnisse der heterotopen Autotransplantation von Milzgewebe nach traumatischer Milzruptur im Kindesalter.

Children and adolescents, who received an autologous reimplant of the spleen because of traumatic injury between 1979 and 1986 were matched to a cohort of patients, splenectomized because of traumatic injury of the spleen as well and to a control group of healthy age matched individuals. In addition to a physical check-up, markers of humoral and cellular immunity (e.g. lymphocyte subpopulations and phagocytosis of pneumococcy) as well as the coagulatory and fibrinolytic system were examined. All parameters tested, were found to between results from splenectomized and healthy individuals. Our studies stress the fundamental ability of autologous spleen transplants to take over part of the splenic function on the basis of a largerly histomorphologic restitution. Thus autologous reimplantation of the spleen in children and adolescents is an excellent choice as compared to otherwise necessary splenectomy, if preservation of the organ is impossible.

[Localized benign pleural mesothelioma]. / Das lokalisierte benigne Pleuramesotheliom.

Benign mesothelioma of the pleura is a very rare tumor. The cells responsible originate from either the mesothelium or the submesothelium. This is why such tumors are described in the literature as fibroma of the pleura, mesothelial fibroma, localized fibrous mesothelioma and monophasic spindle cell tumor. Their growth, is very slow taking several years or even decades. In contrast to the more common malignant mesothelioma of the pleura, it is not related to asbestos exposure. This report deals with a 47-year-old woman patient with a giant benign mesothelioma of the pleura in the region of the right thorax, which was completely removed by thoracotomy.

[Amelanotic melanoma of the rectum]. / Das amelanotische Melanom des Rectums.

We report the very rare case of an amelanotic anorectal melanoma. Until now there are only three other well documented cases of that tumor-type reported in the literature. The course of disease is described from initial symptoms till 10 months after discharge from hospital and suggestions for staging, therapy and follow-up are made.

[Surgical treatment and regional chemotherapy in melanoma of the extremities]. / Chirurgische Behandlung und regionale Chemotherapie beim Extremitätenmelanom.

Since 1979, our treatment protocol for extremity melanoma includes wide local excision, regional lymph node dissection and hyperthermic limb perfusion. We report on the results of a follow-up of the patients treated in the first decade (n = 451). According to the UICC Classification of 1987, 4% of our patients were in stage I, 36% in stage II, 50% in stage III and 9% in stage IV. The respective 5-year survival rates were 93%, 91%, 49%, and 20%. We conclude that regional chemotherapy appears to be beneficial even for stage II patients, as 5-year survival rates of more than 90% can be achieved.

[Pancreatic pseudocysts after blunt abdominal trauma]. / Pankreaspseudozysten nach stumpfen Bauchtraumata.

Pancreatic pseudocyst caused by trauma is rare. Only in 5 of 98 patients on whom we operated between 1977 and 1991 for pancreatic pseudocyst were we able to detect previous blunt abdominal trauma. In a 4-year-old girl just a slight abdominal trauma had given rise to a cyst, while in 2 other patients (aged 9 and 26 years) pancreatitis occurred after trauma that was treated medically. Two patients had to undergo laparotomy immediately after suffering serious abdominal blunt injury. Diagnosis was established sonographically, except in one case, in which a large cyst was determined to originate from the pancreas, but only intraoperatively. The time-span between trauma and treatment of the pseudocyst ranged from 3 months to 1 year. Thus, continuous percutaneous suction, which is basically considered a promising therapy for cysts in their early stages of development, was obviously not feasible in our patients. We therefore carried out cysto-jejunostomy with formation of a Roux-en-Y jejunum loop. At follow up 1-10 years after operation, all patients were asymptomatic and no cyst formation could be detected sonographically.